All posts by Cort Johnson

A New Approach to Fibromyalgia

Infections are a common trigger for fibromyalgia (FM), and fibromyalgia patients are experience many ‘sickness behavior’ symptoms, but we haven’t usually associated FM with viruses or immune system problems.

So it’s going to be Fibromyalgia that gets the really big antiviral trial ….

That’s been changing recently. A immune biomarker has been proposed. Small fiber neuropathy – possibly caused by immune dysregulation – has been found. Dr. Dantini has been treating FM with antivirals for years. The immune system’s starting to get some respect in FM.

Last year we heard that Dr. William Pridgen in Alabama was getting his ducks in a row for a major antiviral trial. Four weeks ago in an email exchange he confirmed that the money – $3.3 million dollars – all gathered from ‘angel investors’ is in hand, and the four-month 143 patient trial began in early October.

A Different Path

The pathways researchers and doctors take to get to disorders like FM or chronic fatigue syndrome are nothing but diverse, and it’s worth taking a look at how Dr. Pridgen, a surgeon, came to fibromyalgia. (Dr. Julia Newton’s pathway to ME/CFS was through elderly people experiencing dizziness and, to her surprise, a great deal of fatigue.) Dr. Pridgen’s pathway to fibromyalgia was through the gut.

Pridgen saw a pattern emerge in his treatment of thousands of patients with chronic gastrointestinal issues that intrigued him. A patient would get better, but then experience a stressful event that would send him/her back into the soup. They would get better, but during the next relapse they would stay sick longer and their recovery period would be shorter. Eventually they would be sick all the time.

Shorter and shorter relapses over time in his patients lead Pridgen to conclude that a virus must be involved.

The problem, he thought, had to be some sort of pathogen that was steadily increasing with every recurrence. Giving his patients antivirals helped, but problems remained. Then he found that adding an anti-inflammatory (which also had anti-viral properties) reduced their fatigue, gastrointestinal complaints, depression and anxiety markedly and improved their energy.

An observational study indicating that the combination drug approach had a 90% ‘efficacy rate’ led Pridgen to start a company, enlist investors and create the large treatment trial.

Pridgen’s theory fits glove and hand with several other fibromyalgia/chronic fatigue syndrome theories. As with Van Elzakkers’ vagus nerve infection theory for ME/CFS, Pridgen’s theory begins with a nerve loving virus that takes up residence – for life – in nerves in the sensory ganglia found across the body.

Instead of HHV6 or EBV Pridgen believes herpes simplex viruses, are the key in FM/ME/CFS. Other than a 1993 theory proposing herpes simplex virus was at play in ME/CFS, interest has been scanty. HSV-1’s ability to affect many of the genes and gene pathways suspected of playing a role in nervous system disorders such as Alzheimer’s, Parkinson’s, depression, chronic fatigue syndrome and autism, however, lead one researcher to propose it could play a role in all of them.

HSV-1 has been found in the esophagus, stomach and duodenum of the gastrointestinal system. In fact, HSV-1 was proposed to cause ‘recurrent functional gastrointestinal disorders’ such as IBS, as far back as 1996.

Pridgen’s patent application indicates that he believes that stressors and peptides and hormones released by the sympathetic nervous system and HPA axis set the stage for herpes simplex-1 reactivation. Pridgen proposes that repeated HSV reactivation can kill the sensory nerve cells ( small fiber neuropathy?) and destroy part of the nerve ganglion. (Stress induced HSV-1 reactivation has been documented in laboratory animal studies.)

Once these neurons and ganglia are damaged, Pridgen believes they send out signals that ultimately muck up the pain processing centers in the central nervous system. The over-generation of neurotransmitters such as glutamate, Substance P, serotonin, norepinephrine, dopamine, brain-derived neurotrophic factor (BDNF) involved in this process then causes central sensitization.

Antiviral Plus

Pridgen proposes to stop the viral reactivation and the central sensitization with antivirals; an approach that’s been tried before in chronic fatigue syndrome, but not in the way Pridgen’s doing it.

Are two ‘antivirals’ better than one? We’ll find out sometime next year.

One of Pridgen’s patent applications suggests that one of his unique insights has been to combine valacyclovir (valtrex) with an anti-inflammatory, Celecoxib (Celebrex) that has antiviral properties. Other combinations are being tested and Pridgen stated they have not released the make-up of IMC formulation used in the trial. It’s not clear, then, what drugs at what doses were used in the study or which will prove most effective.

Pridgen proposes that the two drugs hit the virus at different stages of its life-cycle. Pummeling the virus with that one-two punch, he believes, will finally stop the virus from reactivating.

Pridgen and Duffy are looking for herpes simplex virus, but other herpes viruses could be affected by this treatment. We won’t know if they are until further studies are done.

Inflammation Gone Awry

Pridgen and his partner, molecular virologist, Carol Duffy will also attempt to develop a diagnostic test for fibromyalgia using cytokine arrays they believe will document high levels of pro-inflammatory cytokines and low levels of anti-inflammatory cytokines.

Like VanElzakker, Pridgen believes the body is over-reacting to the virus.

“It’s basically exaggerating its reaction to the virus. Any little stress reactivates the virus, and, rather than the body saying, ‘Oh, this is just a virus I’ve been living with this since I was five,’ the body keeps saying, ‘Oh, my God,’ and throws on all this inflammation, and that gives these people this pain.”

“There is a theory that all pain, one way or another, is inflammation,” Duffy says. “It’s inflammation gone awry.”

Celebrex – The Antiviral?

We don’t hear anything about Celecoxib as a virus fighter in ME/CFS, but some evidence suggests it could be efficacious against herpes simplex virus. The ability of COX-2 inhibitors to decrease prostaglandin production is believed to push the immune system towards a Th1 (antiviral) response and away from the Th2 response often found in ME/CFS.

Pridgen believes Celexicob’s antiviral properties, in concert with Valtrex, will knock down the herpes viruses causing FM and ME/CFS

Celebrex was shown to reduce stress induced herpes virus reactivation in the nervous systems of mice. Another study found that reactivation of HSV-1 in mice was associated with upregulation of COX-2 gene expression in their nerve ganglia. HHV-6 can also induce COX-2 expression. Both COX-1 and COX-2 are needed for viral replication.

(One mother found that VIOXX (now off the market) reduced her daughters IL-6 levels and eliminated the ‘panic attacks’ she’d experienced following a central nervous system infection.)

(Aspirin and flavanoids, vitamin E and fish oils also inhibit COX-2. The efficacy some ME/CFS patients experience from using omega-3 fatty acids could be due to antiviral effects.)

Tissue Biopsies

Along with treating the virus, Pridgen and his partner, molecular virologist Carol Duffy, will be using PCR to test for the virus, not in the blood, but in gut tissue samples.

One of the most intriguing aspects of the Pridgen-Duffy study is the search for HSV-1, not in the blood, but in the tissues. We know the Chronic Fatigue Initiative’s Pathogen study failed to find evidence of viral infection in the blood. Now, Pridgen and Duffy are testing gut samples for herpes virus simplex in their study.

First PCR will be used to search for herpesviruses in both the control and FM gut samples. Then antibodies will be used to determine if an active infection is present. In subsequent studies, electron microscopy will look for the herpesviruses particles themselves.

In preliminary studies 18/19 fibromyalgia patients with gut issues contained herpes simplex virus DNA in their gut tissues. No other herpesviruses were found. Immunoblot testing indicated that an active infection was present in eight of nine positive biopises.

Dr. Pridgen reported in an email they are still trying to determine the optimum doses and cautioned everyone to wait until the results of the phase three trial are done before starting this treatment. He also stated he feels they are ‘very close’ to helping many people with this condition. The results of trial will be released mid-year, 2014.

Conclusion

A successful trial could usher in a new era of treatment for fibromyalgia and perhaps chronic fatigue syndrome

Pridgen and Duffy’s big multi-center antiviral trial in Fibromyalgia is nothing if not exciting in its scope and approach. Pridgen’s ability to come up with over $3,000,000 in startup funding suggests he and Duffy have got some solid data backing their trial up. .

If they results are positive, Pridgen and Duffy could usher in an entirely new way of treating both fibromyalgia and chronic fatigue syndrome.

The more specific requirements of the ICC however, may select patients that are less clinically diverse. This could improve detection of immunological findings in CFS/ME.

Study authors.

How much of a difference the International Consensus Criteria (or any definition) makes is a major question in chronic fatigue syndrome.

Dr. Sonya Marshall-Gradisnik’s team in Australia, who just celebrated the grand opening of the National Centre for Neuroimmune and Emerging Diseases at Griffith Univeristy, examines this question in a recent study. Dr. Marshall is a leading ME/CFS researcher, as well as a member of Simmaron’s Scientific Advisory Board.

Proponents of using a more restrictive definition such as the CCC/ICC believe that winnowing out a homogeneous group in research studies could be the key to figuring out ME/CFS. Once ‘non-ME/CFS patients are eliminated, core factor will pop out and be quickly replicated. It’s an enticing vision.

Others worry that a more narrowly focused group might miss some legitimate ME/CFS patients. The ‘wider net’ approach, may have been embodied in the ’empirical definition’, which grabbed a large set of ‘CFS’ patients, from which subsets could conceivably have been winnowed.

This strategy would have the benefit of applying to a larger population (up to 4 million in the US), and might work well if the funds and will had been available. Without that commitment that strategy runs the risk of producing almost meaningless results.

A recent publication by Dr. Sonya Marshall-Gradisnik’s team compares the immune functioning of ME/CFS patients meeting the International Consensus Criteria vs. those meeting the Fukuda/1994 CDC definition, giving us a start on determining the pros and cons of a more narrow vs. a broader approach to ME/CFS research.

Fukuda/1994 CDC Definition

The fact that few research papers in the last twenty years used something other than the 1994 Fukuda definition to define their participants means that virtually all the findings in ME/CFS from the natural killer cell dysfunctions to low blood volume to exercise intolerance, etc., have all been found using the Fukuda definition. By putting all researchers on the same playing field, the Fukuda definition has played an important place in the history of ME/CFS research, but its vagueness and its inability to highlight what many believe to be the key symptom in ME/CFS means it almost certainly allows several questionable subsets into research studies.

The Study

Sixty-three participants including 41 people with ME/CFS and 22 controls answered questionnaires and gave blood samples. The blood samples were assessed for immune functioning. All patients had been previously diagnosed with chronic fatigue syndrome at the National Centre for Neuroimmunology and Emerging Diseases, a top ME/CFS research lab (and soon to be clinic) led by Dr. Sonya Marshall-Gradisnik in Australia. (Dr. Marshall-Gradisnik serves on the Simmaron Research Foundation’s Board).

Results

The breakdown was fascinating. Seventeen people met the Fukuda criteria but not the ICC, and 18 people met both the ICC and the Fukuda criteria. Five people — over 10 percent — of the ME/CFS patients met neither criteria. This was one small study, but it did suggest that a large percentage of people that doctors identify with ‘chronic fatigue syndrome’ may not meet the ICC, and another substantial subset may not meet either criteria. It does not bode well for a more restrictive approach to ME/CFS.

Natural Killer Cells

It was no surprise to see reduced NK cell functioning show up in both the ICC and Fukuda groups. This reduced natural killer cell functioning is believed to inhibit the ME/CFS patient’s ability to clear new infections and/or stop recurring infections. (Interestingly, reduced NK cell function was not associated with alterations in the cytotoxic factors – granzymes and perforin – that NK cells use to kill cells, as has been seen in the past. The authors suggested, however, that this might have been due to the small sample size.)

Immune Suppression Enhanced in the ICC Group

Both groups demonstrated immune suppression, but the immune suppression was significantly increased in the ICC patients. The increased prevalence of two inhibitory or suppressive immune factors in the ICC group suggested a) they were a distinct group, (b) the promise of more abnormalities showing up when a more restrictive definition was used was fulfilled and c) that their immune system was having more trouble than the Fukuda group’s in becoming properly activated. Treg or T regulatory cells or ‘suppressor’ T-cells are rather new to the scene in ME/CFS, but this is the third study showing significant increases in these cells. That suggests they may play an important role in chronic fatigue syndrome. High levels of Treg cells could be suppressing natural killer cell functioning in ME/CFS.

Both groups exhibited reduced immune activity, but more immune suppression was found in the ICC group

KIR Receptors – High levels of ‘KIR’ receptors on the NK cells of the ICC group (but not the CDC group) could further suppress NK cell function. The presence of two ‘profoundly’ inhibiting factors suggested the ICC group’s immune systems were getting particularly hammered. (Increased levels of an ‘activating’ NK cell receptor were also found. The authors felt this resulted from an attempt to balance the ‘overwhelming’ inhibitory signals from the two inhibitory receptors.) (Receptors on the surface of a cell greatly influence what the cell does. NK cells that are dotted with inhibitory receptors, for instance, can be easily turned off. Conversely, NK cells with few inhibitory receptors will be difficult to turn off.) The authors suggested, but could not prove, that the ICC group carried genes that promoted a tendency towards NK inhibition.

Hitting Home – Physical Functioning Affected

One of the vital questions regarding the abnormalities in ME/CFS is how much they matter. Ironically, THE immune finding in ME/CFS, poor NK cell functioning, didn’t pan out in this regard. While low NK cell functioning was associated with poorer health in the healthy controls, it didn’t appear, at least in this small study, to be correlated with poorer health in the ME/CFS groups. Decreased CD39+ and altered KIR receptors were, however, ‘strongly’ associated with poorer health in the ICC (but not the Fukuda delineated patients). This suggested that immune suppression was having an impact in the ICC delineated patients.

Touchy Situation Ahead

The increased amount of immune suppression in the ICC group suggested that the ICC criteria did select a more immune-challenged set of patients and that group should be set apart for separate study. The immune findings in the Fukuda group (low NK cell functioning/increased Tregs) were nothing to sneeze at, however. Plus, the high percentage (almost 50%) of patients meeting the Fukuda criteria, but not the ICC criteria indicated that group cannot be ignored. The ten percent of people with ME/CFS that met neither criteria suggested an important subset of people who are sick, but don’t meet either criteria, may be present. The fact that all the study participants were identified by ME/CFS researchers/doctors working at an ME/CFS lab suggested they were indeed ME/CFS patients. These researchers proposed that both groups should be included in studies. Since all the people that met the ICC also met the Fukuda/1994 CDC criteria, starting off with the Fukuda criteria and then examining the ICC criteria patients could achieve this.

Conclusion

“These findings are highly suggestive of a need to incorporate both the 1994 CDC and the ICC in future clinical research”

Study authors

With a new research definition coming up on the docket, it was good a see a study examining a prominent candidate — the International Consensus Criteria.

With this study suggesting both definitions have merit, determining how wide or narrow of a net to cast in the research definition will not be easy.

The IOM contract for a clinical definition was really just a prelude to the big problem looming ahead, which is creating an appropriate research definition.

Since the research definition defines what types of patients participate in a study, its use can fundamentally alter how a disorder is viewed or researched.

The suppressive nature of the immune dysfunctions found in the ICC group suggested, to my mind, that they might be ‘Fukuda plus’ patients dogged by increased levels of immune suppression.

This study gave no clear answers. It suggested that patients that meet the Fukuda criteria but not the ICC criteria are an important subset of ME/CFS, but it also suggested that segregating patients meeting the ICC criteria could help uncover more immune abnormalities.

Communication was central to all of our activities

My first memory of Dennis Mangan came at the end of a long day at a Federal Advisory Meeting for ME/CFS (CFSAC). As the meeting broke up, Dennis strode over, pulled up a chair and motioned for everyone to gather around. He asked what we thought needed to happen. For the next hour or so he sat and quietly, listening to stories of distress, frustration and hope. Never had anyone from the National Institutes of Health attempted to get so close to the patient community. Changes, I thought, were surely in the wind.

Dennis Mangan created the State of the Knowledge Conference, created a Listserv, re-vitalized the CFS Working Group, changed the name and communicated, communicated, communicated during his time working on ME/CFS at the NIH

After that he started to act. He redid the NIH website, and they became the first federal agency to call chronic fatigue syndrome ‘ME/CFS’. He started a Listserv to be in better communication; he enlarged and revitalized the NIH Working Group (they had their first meeting in a year). Soon we had State of the Knowledge Workshop – put together in collaboration with patients. Throughout, Dennis was open and in communication, and the ME/CFS community embraced him. It was like day and night at the NIH.

Dennis Mangan ended his career at the NIH as the head of the CFS Working Group at the NIH. You could argue that everything in his career lead him there, and that his experiences there have continue to inform his current activities.

With a Ph.D. in biology (dissertation – “Mannose sensitive interaction of Escherichia coli with human peripheral leukocytes in vitro“), Dennis did hard-core immune research for 15 years, before moving to the National Institute of Dental and Craniofacial Resarch (NIDCR) at the National Institutes of Health (NIH).

As director of the Infectious Disease Program NIDCR Dennis engaged in numerous activities including identifying key research areas, designing major trans-NIH efforts on mucosal immunity, biofilms and the microbiome, leading the Human Microbiome Project, liasing with professional groups, developing funding opportunities, etc. A member of Information Technology Advisory Committee, Dennis produced the first Listserv to provide infectious disease researchers with up to date funding opportunities.

At the Office on Research on Women’s Health (ORWH) in 2009 Dennis developed strategic plans, identified opportunities for growth, etc., and chaired the NIH Working group on ME/CFS. His commitment to open and effective communication was put to the test with a frustrated and often suspicious ME/CFS community that ended up embracing him.

Family issues prompted Dennis’s retirement, but he promised to stay engaged with the ME/CFS community, and he has. Now, as he joins the Scientific Advisory Board of the Simmaron Research Foundation, I asked him about the federal government and his work with Simmaron and the ME/CFS community.

Interview

“I never left”

When you retired in late 2011 you promised to stay engaged with the Chronic Fatigue Syndrome community and you have. Since then you’ve chaired a session at the FDA Workshop for ME/CFS, become an Advisory Board Member for the Stanford Chronic Fatigue Research Group, a Board Member for the IACFS/ME, and now the Simmaron Research Foundation. That’s a lot of stuff. Am I missing anything?

That pretty much covers it. In addition, since 2011, I took a variety of communication classes so that I might help scientists talk about their work with the public they serve and the people who support their research. Public interactions, of course, have direct application to increasing the awareness of CFS and related disorders.

I give workshops in which the researchers learn to be more conversational, boil down complex data, explain their research briefly (elevator pitches), and talk about research in the form of stories instead of cold facts. Improved communication will, I hope, help science become more transparent to everyone, including news media, legislators, funding agencies, administrators, donors, students, patients, family and friends.

I’m not sure helping out the sometimes surly ME/CFS community would fit into many people’s retirement plans. You could surely have found easier subjects to be engaged with, yet you’ve committed a good chunk of energy to supporting this community. Why? What has made you come back?

Dennis Mangan’s forte has been bridging the gap between patient and researcher and bringing people together to work on disease.

I never left. Helping connect the research scientists with the public has been my career for 30+ years. There is much excitement and promise in what is happening in science right now (e.g., genomics, high throughput technologies, regenerative medicine, the microbiome, systems biology) and I see opportunities for that science to have direct impact on our understanding and treatment of CFS. When I retired from civil service as an advisor to the NIH, I continued to talk with patients as well as researchers. By learning more about how to communicate science to the public, I found a way to contribute to the progress in the CFS field.

You’re a past researcher, you’ve checked out the research on ME/CFS as well as disorders allied with it. Is there anything that really pops out for you? That says to you – this is what ME/CFS is all about?

Like many others, I am impressed with the findings related to disorders of the neuro-immune system and infectious diseases studies. They seem to point to an abnormal response of the body to microbes (viruses or bacteria) that might ultimately serve as both biomarkers of disease and targets for treatment. The similarity of some CFS features with other diseases suggests there might be common pathways.

My NIH colleagues and I strived for transparency in order to increase awareness for CFS at all levels of NIH leadership

You were the NIH representative and Chair of the ME/CFS working group at the NIH from 2010 to 2011 – a short time! – but you made a big impact. You enlarged the NIH Working Group on ME/CFS, created a Listserv, changed the name to ME/CFS, remade the NIH website, and communicated, communicated, communicated. It seemed to me that you really had a vision that you wanted to accomplish and a big part of that involved communication. Can you speak about that?

The State of the Knowledge Workshop on Chronic Fatigue Syndrome was the first ME/CFS focused Workshop sponsored by the DHHS in almost 10 years.

Communication was central to all of our activities. My NIH colleagues and I strived for transparency in order to increase awareness for CFS at all levels of NIH leadership, among researchers and within the patient/advocate communities. We all wanted to advance the science of CFS and to translate basic laboratory research into clinical practice.

As experienced program directors at NIH, we knew that exchange of ideas and scientific debate moves research fields forward. To that end, in cooperation with leadership at the Office of Research on Women’s Health and the Office of the Director, the Working Group designed a unique State of the Knowledge workshop on CFS in April 2011.

The intent was to bring together basic and clinical researchers from many disciplines to share their knowledge and help point to where future research was headed. It truly was a workshop. The meeting generated great discussions and some collaboration. It also emphasized the need for access to common data that spawned the goal of a shared database of clinical information.

The database, which we referred to as the CASA (i.e., home) project, is currently under construction. Simmaron Research, with its wealth of clinical data, is a participating contributor.

Simmaron’s openness to working with other researchers makes them a great partner in studying and treating CFS.

Why did you chose the Simmaron Research Foundation to work with?

The CFS groups that I work with have common features. They all have a passion to solve the mysteries of CFS using the best scientific principles. They all value collaborative and cross-disciplinary research. Simmaron incorporates these values in all their work. The group has limited resources but leverages what they have with other laboratories. In particular some of their biospecimens reach back almost 30 years and when shared with others can have spectacular impact on medical discovery.

Mangan cited Simmaron’s professionalism and willingness to creatively collaborate with other groups as two reasons for joining their board.

Although a small organization, Simmaron offers extensive clinical expertise and biospecimens for medical research. Moreover, their clinics are designed to capture important information about CFS patients that could lead to better diagnosis and treatment. I greatly admire their creative administrative structure, and the connection with a non-profit umbrella organization that maximizes resources and reduces operating expenses.

Simmaron’s openness to working with other researchers makes them a great partner in studying and treating CFS. Simmaron is also committed to developing the next generation of CFS clinical researchers and has established an advanced training fellowship program for physicians. Moreover, Simmaron has helped increase public awareness for CFS in many public sectors.

To my knowledge, never before has CFS taken such a front stage position within the Department.

Dr. Wanda Jones told me earlier this year that significant shifts in the federal governments attitude towards chronic fatigue syndrome (ME/CFS) have occurred, but that we, for the most part, don’t see them, in part because of the ongoing budget situation. Is that your experience? Did you see shifts in how ME/CFS was viewed when you were there?

Wanda Jones was a terrific resource and a friend to me. She worked tirelessly to connect the various DHHS agencies’ efforts to address the needs CFS patients and researchers. She was always down to earth, direct and honest with me, and did not pander to anyone. I used her passion as a building block for my efforts at the NIH. We all wanted more funding for CFS research and to encourage more scientists from multiple disciplines to enter the field.

My guess is that the changes I saw happening at the NIH are also happening at the DHHS now. Deputy Secretary Howard Koh and Nancy Lee, Director of the Office of Women’s Health, are keeping CFS on the “radar screen” at the DHHS. Sometimes even within the government we don’t know what is happening at all the agencies. Koh is working to increase transparency within the DHHS (e.g., when I was there he hosted monthly teleconference calls among the heads of key agencies involved in CFS.) To my knowledge, never before has CFS taken such a front stage position within the Department.

People with ME/CFS look at NIH funding and they, honestly, want to scream. They feel abandoned and angry at the little support the federal government gives to this disorder. It’s not as if we’re alone, though. Fibromyalgia, IBS, interstitial cystitus and other ‘allied disorders’ also get funding that is out of sync with their prevalence and the degree of suffering they cause. These are all complex disorders that primarily affect woman and cause a lot suffering but don’t usually cause death. Why do you think these types of disorders receive low amounts of funding relative to other chronic illnesses?

I know…I received a few of those screams directly…but they did not land on deaf ears! We might be one experiment or observation away from a breakthrough in CFS and every experiment is important. The key to scientific credibility is to have validated biomarkers and targets for treatment.

This is why the XMRV story went viral: we finally had a target. As a result, funding for CFS spiked in 2009 and several grants were awarded to study aspects of XMRV. If we could reduce the scientific complexity of CFS (e.g., by having good biomarkers and targets for treatment), I suspect that more researchers would want to invest a career in studying it. Such knowledge breeds an intellectual feeding-frenzy for research, new researchers and more funded grants.

The NIH never moves as fast as I would like.

Dennis Mangan played a key role in launching the Human Microbiome Project to study the microbial populations present in humans. If Dr. Ian Lipkin is correct, the the gut microbiome may play a crucial role in ME/CFS.

If there’s one thing you’d like people with ME/CFS to know about federal government and its approach to chronic illness what would it be?

Patience and persistence is necessary. The NIH never moves as fast as I would like. For example, in the late 1990s, I recommended NIH support more projects on high-throughput sequencing of microbes in order to advance our understanding of both pathogens and the microbes that normally colonize our healthy bodies. NIH leadership, many of my colleagues and some researchers were reluctant to support such projects, labeling them as fishing expeditions in which massive amounts of data would overwhelm existing computer technology, and waste funds and resources.

It took me six years working with likeminded colleagues at the NIH and other agencies to finally see the Human Microbiome Project (HMP) get funded ($173+ million to date). Today, the HMP project is generating new technologies (e.g., faster computing software and hardware), new hypotheses of diseases and conditions (e.g., a better understanding of how gut microbes are involved in allergies and obesity), and a new generation of infectious disease researchers (e.g., Ian Lipkin.)

What could the chronic fatigue syndrome patient community be doing better to get its needs satisfied?

I have found the patient communities to be thoroughly engaged and eager to learn more about the pathophysiology of CFS. Past history makes it hard for some patients and advocates to have hope for government support for their illness. “Hardliner” skeptics are eager to create conspiracy theories for everything.

However, many patients and I understand the value of scientific principles and debate. We saw science work with XMRV. Yet, while the debate was ongoing, theories of the government hiding data abounded as scientists worked on replicating experiments and getting the truth out about XMRV.

What patients might not realize is that researchers also need hope and encouragement to move forward. I encourage all of us to offer researchers a few kind words of support and to inspire them to keep working on the illness.

Besides more funding, what could the federal government be doing better to satisfy the needs of the ME/CFS community?

Resources for scientific discovery come in various forms. My colleagues on the Trans-NIH ME/CFS Research Working Group understand this very well. Although funding is always at the top of our list, we recognize other ways to support CFS research. This includes support for research conferences; increasing awareness of the illness in the government, the medical communities and general public; support for training and career development; and public-private ventures to leverage limited financial resources.

The reasons for the Institute of Medicine and NIH evaluation of case definitions still puzzle me

How important would having a federally recognized clinical or research definition be? Would that open doors that are now closed?

I think clinical and research definitions are extremely important for the future of the study and recognition of CFS. Having a diagnosis take months, and needing to exclude so many other diseases and conditions, stifles understanding of the etiology and pathogenesis of CFS. The current definitions could greatly be aided by a biomarker, and, with more research, these are gaining validation.

The reasons for the Institute of Medicine and NIH evaluation of case definitions still puzzle me. However, I do know that the government as a basis for larger initiatives sometimes uses such evaluation reports. I remain hopeful that the DHHS has such initiatives awaiting the outcome of these reports.

We will publish data very soon on biomarkers of cytokines. Our evidence now suggests there is ongoing stimulus to the immune system. Dr. Ian Lipkin

You don’t usually get study results in talks like the one put on by the CDC yesterday but this time Dr. Ian Lipkin spilled the beans on the results from the big pathogen studies sponsored by the Chronic Fatigue Initiative (n=200) and Dr. Montoya (400). (From notes taken on the talk)

Virus Study Results Revealed

Viruses have always been the elephant in the room in ME/CFS; everybody has wondered about them but until the Chronic Fatigue Initiative came along, few major studies had been done. This landmark study, using the one of the top virus hunters in the world and epidemiologist Mady Hornig, and containing hundreds of patients from ME/CFS specialists (Dr. Peterson, Klimas, Montoya, Levine, etc.) from across the country, sets a benchmark for pathogen research in ME/CFS.

A special feature of the study involved Simmaron Research’s spinal fluid samples. Called a ‘unique resource’ earlier by Dr. Mady Hornig, these samples allowed the researchers to get as close to the brain – long thought to be a key area in chronic fatigue syndrome – as they could. And the spinal fluid results were spectacular.

The Studies

This study funded by the CFI, using top labs, and involving hundreds of people with ME/CFS, is a benchmark in ME/CFS research.

The studies looked at both pathogen presence and the immune response in hundreds of people with chronic fatigue syndrome.

Pathogens

First Phase – Screens for 18 specific pathogens already implicated in ME/CFS (herpesviruses, HTLV, enteroviruses, West Nile Virus, etc.) were done on blood from Montoya’s patients and the CFI’s group (Dr’s Peterson, Klimas, Bateman, Levine, etc.). Dr. Lipkin was looking for the virus, not a indication it was present, but the virus itself. Any finding of a virus in the blood would indicate it was active. The same screen was done on Dr. Peterson’s sixty spinal fluid samples.

Second Phase – The second phase involved sequencing all the DNA/RNA in the blood to identify known and unknown viruses. Dr. Lipkin’s lab has been able to identify hundreds of novel viruses using this technique.

Third Phase – Any finds in the second phase are confirmed/denied by more accurate testing.

Immune Response

Active Viruses Strike Out

Four of the 285 ME/CFS blood samples tested positive for HHV-6B. One of the sixty spinal fluid samples tested positive for a virus (HHV-6B). None of the other viruses commonly associated with ME/CFS (Epstein Barr-Virus, enteroviruses, the cytomegalovirus, etc.) commonly associated with ME/CFS showed up in the first pathogen screen.

The high throughput screening designed to look for any viruses including novel viruses drew a blank as well. Dr. Lipkin was confident in his results stating his lab had found over 500 new viruses using this technique.

Lipkin’s search for 18 viruses and for novel viruses in hundreds of people with chronic fatigue syndrome largely turned up empty

The news – that fewer than 2% of patients with infectious onset – tested positive for viruses in the blood was stunning but not without precedent. Dr. Unger reported earlier that the first stage of the CDC’s BSRI pathogen study drew a blank. A spinal fluid study also turned up no viruses, and PCR analyses done by the Dubbo group were unable to find evidence of a virus in their post-infectious cohort.

With two large sample sets turning up negative in the lab of one of most acclaimed virus hunters on the planet, it’s probably safe to say that the hunt for an virus in the blood of people with ME/CFS is over.

(Lipkin did report 85% of pooled samples possibly showed evidence of a retrovirus but believes they will not be related to CFS. He also dismissed earlier rumors that a novel infectious agent had been found.)

Infectious Agent Still Proposed

That doesn’t mean an infectious agent is not involved. In fact, Dr. Lipkin stated he didn’t doubt that an infectious agent was involved. He didn’t say where and he didn’t say it was still present. His allusion to the importance of finding evidence of a past infection (“researching the shadows”) suggested he could be leaning to the ‘hit and run’ hypothesis where a pathogen sweeps in, does its damage, and then gets removed by the immune system.

The Dubbo studies’ finding that high cytokine levels early in the infection were strongly associated with getting ME/CFS later on suggested an overactive immune system may have a blown a few fuses somewhere.

On the other hand, Dr. Lipkin specifically alluded to an ‘agent’ driving the immune activation he found in both the blood and spinal fluid of ME/CFS patients (but not the healthy controls).

Localized Infections Still Appear to Be a Possibility

Dr. Lipkin didn’t discuss this possibility. The blood is the most convenient place to search for an virus and active viruses usually do travel through the blood but central nervous system or localized infections may not show up in the blood or the spinal fluid.

Some evidence of localized infections in the gastrointestinal tract has been found in ME/CFS. A De Merileir team found evidence of HHV-6, EBV and parvovirus B-19 in 15-40% of gut biopsies. Eighty-two percent of stomach biopsies tested positive for a protein associated with enteroviruses in Dr. Chia’s 2008 study. Dr. Chia reports enteroviruses are found much more readily in the stomach than the blood (but he is able to find it in the blood). No enterviruses were found in the present study.

Vanelzakker proposes that a localized vagal nerve infection is causing the symptoms in ME/CFS. It’s not clear what these results mean for Dr. Lerner’s theory that an aborted EBV infection is spilling viral proteins into the blood that are sparking an immune result.

The Three Year Breakpoint

Data suggests there may be substantial differences in biomarkers in people with less than 3 years of disease and those with more than 3 years of disease. Dr. Lipkin

Two recent research findings suggest the immune systems of people with recent onset and longer duration ME.CFS are significantly different.

Echoing similar recent findings from the Broderick/ Klimas team at NSU, Dr. Lipkin stated the immune system in ‘newbies’ (patients with recent onset), and patients with a longer case of ME/CFS was different. Dr. Lipkin’s ability to independently differentiate ‘newer’ from ‘older’ patients using cytokine results is pivotal, and points to the central and progressive role the immune may play in this disorder.

With Broderick suggesting that two distinct illnesses emerge over time, and Lipkin proposing treatment options should reflect illness duration, it was clear these changes were significant indeed.

Natelson, on very different track, is finding changes over time as well with more POTS in his adolescents and a different kind of orthostatic intolerance in older patients. Studies are underway to understand why this might be so.

An Early Allergic Response

Allergy is not usually mentioned in association with ME/CFS but eosinophils and other markers suggested to Dr. Lipkin that the allergic response was enhanced in ME/CFS early on. The cast of immune characters Lipkin’s biomarker search fleshed out was refreshingly familiar with IL-17, IL-2, IL-8 and TNF-a leading the list.

Levels of Il-17 were raised in recent onset ME/CFS patients. Lipkin suggested immunomoculators able to bring IL-17 levels down might be a treatment option at some point.

No mention, interestingly, was made of autoimmunity, but Lipkin, pointing at the high IL-17 levels in the newbies, embraced the idea (only after further validation) of using immunomodulators in some ME/CFS patients to turn down the fire in the immune system. Immunomodulators exist now, he said, that can bring that IL-17 cytokine down. (He stressed, however, that there is not enough research to start using them on patients.)

The spinal fluid, interestingly enough, showed a very different pattern. It showed a consistent profile of immunological dysregulation in CFS, regardless of duration of illness. Dr. Lipkin identified increased IL-10 and IL-13 levels suggesting enhanced Th2 activation and increased IL-1B, IL-5 and IL-17 suggesting Th1 (proinflammatory) activation. Dr. Lipkin was obviously intrigued by the differences in cytokine findings between spinal fluid and blood.

A Focus on the Gut

I think the gut microbiome is going to be where the action is (in chronic fatigue syndrome). Dr. Ian Lipkin

Lipkin’s prime focus at this point is the gut and fecal matter. He believes the gut microbiome is going to play a, perhaps the key role in ME/CFS.

The Hornig/Lipkin team has had considerable experience with the gut microbiome. They’ve been successful finding gut abnormalities in autism, a disorder that shares some intriguing commonalities with ME/CFS, including low natural killer cell functioning. Noting that the gut can modulate immune functioning, not just in the gut, but across the body he asserted the gut is going to be ‘where the action is’ in ME/CFS.

Lipkin believes ‘the action’ in ME/CFS is going to take place in the gut microbiome (flora)

Unfortunately, the fecal samples originally collected didn’t provide enough material for analysis so they’re restarting that part of the study.

Even more unfortunately, characterizing the bacteria in fecal matter is extremely expensive and with Lipkin, with just 10% of the money needed to do the job, evidenced considerable frustration at having his hands tied by lack of money.

Stating that he was not pointing fingers, he then proceeded to point them everywhere: at federal politics of funding, at NIH budget cuts, and at the paucity of research funding in our field. As at his last public talk, he urged patients to get active and enlist their congressman in their cause. Oddly enough, he also said Dr. Fauci, long considered a kind of ME/CFS nemesis by patients, was supportive of more work in this area.

Reiterating his belief that chronic fatigue syndrome has pathophysiological roots, Lipkin noted his history with it. Dr. Lipkin’s 1999 ME/CFS study did not find the virus he was researching but it did find a great deal of immune (polyclonal B-cell) activation, a pattern that was recently repeated when he didn’t find XMRV but was impressed by the evidence of immune activation he did find.

Next Up

Lipkin, in close collaboration with his ME/CFS experts, Dr. Peterson, Dr. Montoya. Dr. Klimas, Dr. Komaroff, etc. is following these results with deep sequencing of samples, completion of fecal matter analysis and larger studies to confirm and deepen the understanding of cytokines as biomarkers. Protein analysis was not mentioned but it was part of the original project. Tracking down evidence of past infection was also on the agenda.

Conclusion

The Chronic Fatigue Initiative’s pathogen study set a benchmark for rigor and size in the ME/CFS research field, not the least because of Dr. Lipkin’s leadership. Surprisingly few viruses were found in the blood of ME/CFS patients, yet Lipkin asserted that an infectious agent was likely driving the immune activation he found in the blood and spinal samples. Cytokine analyses of the blood suggested a different pattern of immune dysregulation was present in newer onset patients (<3 years) and patients with a longer duration of illness.

Dr. Lipkin believes the “primary cause is likely to be an infectious agent” and the gut microbiome is where ‘the action’ will be in ME/CFS.

A lot of interesting viral possibilities have been raised in chronic fatigue syndrome (ME/CFS) over time, but this virus, possibly found in every cell of a persons body, might just take the cake.

ciHHV-6 – The Wrong Kind of Integration

Most people are exposed to HHV-6 early in life and carry a latent form of the virus in their body. Usually benign, immune suppression can allow HHV-6 to become reactivated causing fever, seizures, encephalitis, cognitive problems, heart disease and more.

Some people have HHV-6 integrated into every cell of their body

ciHHV-6 is different though. Two HHV-6 viruses (HHV-6A and HHV-6B) that probably jumped into the human germ at some unknown point several hundred thousand years ago, now some people carry a copy of it in the DNA of every cell of their body; that’s right – every cell of their body.

Does the thought of having a potentially harmful herpesvirus genome present in the DNA of every cell of your body send a little shiver up your spine? It certainly does mine, but before anyone panics let’s recognize that our DNA is larded with all sorts of weird stuff including many old (mostly beaten up) viruses. (Fragments of retroviruses make up about 8% of our genome) Almost all of us have also been infected by 5-8 of the 9 herpesviruses that can smack us hard if our immune systems let them get out of line. We carry toxic species of bacteria in our guts. We’re full of surprises, but the idea that a potentially damaging herpesvirus exists – fully intact – in some people’s DNA calls for more research.

Studies of approximately 6,000 blood and cord blood donor tests indicate 0.8% or slightly less than 1% of the US population, most of whom are in good health, have ciHHV-6. Tests on people with chronic illnesses are less extensive, but early studies suggest increased rate of ciHHV6 integration are present in numerous neurological disorders including children suspected of encephalitis (3.26%), non-Hodgkins Lymphoma (3.13%) and multiple sclerosis (2.86%).

The first of its kind in chronic fatigue syndrome, this study, led by a respected herpes virus researcher (and in collaboration with Dr. Jose Montoya of Stanford University and Dr. Dan Peterson of Simmaron Research), determined whether a kind of human herpes virus 6 infection called ciHHV-6A or ciHHV-6B was present in a subset of patients diagnosed with chronic fatigue syndrome.

Misdiagnosis Presents Dangers

Even in its benign, unactivated state ciHHV-6 can produce lab test results that make it look like you have roaring HHV-6 infection when you do not. The high viral loads that are a distinctive feature of ciHHV-6 present a danger when physicians, believing the patient has a raging HHV-6 infection, prescribes unneeded and potentially dangerous antivirals.

Misdiagnosing ciHHV-6 as an active HHV-6 infection can lead to unneeded and possibly dangerous antiviral -treatment

In fact, high levels of HHV-6 (> 5.5 log10 copies/ml of HHV-6 in whole blood) on quantitative PCR tests are considered a definitive indication that ciHHV-6 is present unless a patient is acutely ill. HHV-6 appears to be largely localized in the tissues in ME/CFS, and therefore doesn’t leak a lot of HHV-6 into the blood. (Very high levels of HHV-6 DNA can be found during primary (or first) infections, but this type of infection is not usually seen in ME/CFS).

Even in primary infections HHV-6 loads will diminish over time in the blood. That doesn’t happen with ciHHV-6.

Since a latent ciHHV-6 infection is contained within the cellular DNA, the result on a serum or plasma PCR test is much lower because the cells are separated from the plasma and only DNA from cells that die in the process will show up.

The Study

Three hundred and thirty seven people suffering from neurological problems and long-term fatigue were tested using quantitative PCR for the presence of ciHHV-6. Very, very high levels of HHV6 indicated that two percent (7/337) had chromosomally integrated HHV-6. mRNA tests indicated the virus was actively replicating in their blood.

Two percent (2.1%) of the ME/CFS population translates into about 15-20,000 people with ME/CFS in the US.

Findings

Not Homegrown After All

This study suggests that, in symptomatic ciHHV-6 patients, infection with an exogenous HHV-6 virus may be a frequent occurrence.

The second part of the study involved four ciHHV6 patients suffering from symptoms consistent with ME/CFS including debilitating fatigue, headache, blurred vision, cognitive impairment, pain, etc. who were given further testing to determine the type of HHV-6 present. All had an active infection of different strain of HHV-6 virus than found in their genome. That suggested their illness was not due to ciHHV-6 reactivation but to another strain of HHV-6 they’d been exposed to.

It also suggested that people with ciHHV-6 and neurological symptoms such as fatigue and cognitive problems may very well have two HHV-6 infections; the ciHHV-6 in their DNA and an outside infection.

Long-Term Antiviral Treatment Provides Hope

The good news…Is that antiviral drugs improve the severe neurological symptoms, including dysfunction and long-term fatigue, suffered by a certain group of patients with CFS. Dr. Peter Medveczky

Two treatment regimes, a short-term regime (900 mg/valganciclovir 2x’s/day) lasting 3 weeks and a longer term (900 mg/valganciclovir 2x’s/day for first three weeks then 450 mg twice daily for three weeks or more) lasting greater than or equal to six weeks. The short-term treatment had no effect on viral load (U100 RNA) or symptoms while the long-term treatment eliminated both. A blood test five weeks after the end of the treatment for one patient, however, indicated the virus was back in full force.

(Note that Valtrex, an antiherpesvirus drug commonly used in ME/CFS, is not effective against HHV-6)

Valganciclovir (Valcyte) is effective against HHV-6; (valaciyclovir) Valtrex is not

Kristin Loomis, the Executive Director of the HHV-6 Foundation, suggested patients with active ciHHV-6 infections may also benefit from supplements that enhance their cellular immune response such as AHCC, ImmunoPro, and Avemar, or the prescription drug Immunovir that can be ordered legally from Canada with a prescription.

Last year Medveczky and Montoya reported successfully resolving the neurological symptoms and fatigue of two ciHHV6 patients experiencing cognitive problems, depression, fatigue, and abnormal qEEG readings. Their qEEG readings normalized and their DNA load declined although, (as expected), it did not disappear. According to the Pantry study they remain symptom free.

Kristin Loomis suggested one reason these patients may need longer than normal treatment regimes is a long lasting immunosuppression caused by HHV-6. She noted that the beta herpesviruses (HHV-6, 7 and CMV (HHV-5)) found in ME/CFS all cause immunosuppression that can last up to six months. Until the immune system is restored, these virsues will continue to reactivate during stressful periods or in response to another illness.

ciHVV-6 Opens The Door?

Why the ciHHV-6 patients were infected with a different HHV-6 strain than they were harboring isn’t clear, but several possibilities exist. Findings of reduced antibody rates to an HHV-6 protein suggest ciHHV-6 may somehow have switched off some immune factors that target HHV-6, thereby opening the door for new HHV-6 infections.

Some preliminary evidence suggests ciHHV-6 could open the door for more HHV-6 infections

Kristin Loomis, the President of the HHV-6 Foundation that helped fund the study, noted that many people with recurring herpesvirus infections (ciHHV-6 or not) probably have an undiagnosed immune deficiency such as hypogammaglobulinemia, impaired CD4 or NK cell responses, reduced lymphoproliferative response and/or low NK cell counts. The following tests at a lab such as Quest can identify these some of these immune ‘holes’.

IgG Subclasses Panel

Lymphocyte Subset Panel (CD4, CD8, CD3, CD19 and CD16/56)

ImmuKnow Immune Cell Function (measures CD4 cell response)

Natural Killer Cell Functional Assay, FC

Other causes of viral reactivation include stress. (Hydrocortisone activates virus in the laboratory.)

Drugs Open the Door?

Laboratory cell culture studies suggest the possibility that in some cases drugs may have opened the door for ciHHV-6 reactivation. Antibiotics such as Amoxicillin, Minocycline, Vancomycin, Dapsone, Trichostatin; NSAIDS such as ibuprofen and naproxen; immunosuppressants such as hydrocortisone; anti-inflammatories such as sulfasalazine, anticonvulsants such as carbamazepine, phenobarbital, valproic acid and HDAC inhibitor Trichostatin A have all been found in laboratory culture tests or in case reports, to enhance the risk of HHV-6 reactivation. (Click here for more drugs – Table Four).

Extreme drug allergies (also known as Drug Induced Hypersensitivity Syndrome or DRESS) result in HHV-6 reactivation in about 85% of cases. Steroids can also activate HHV-6; it is unknown if they present a unusual risk to individuals with ciHHV6, however.

Tested Positive for HHV-6? You Probably Have ciHHV-6

A team of ciHHV-6 experts does not recommend routine screening for ciHHV-6 for the general population but does recommend that patients with ‘suspiciously high’ serum or plasma HHV-6 levels get screened using quantitative PCR using whole blood or PBMC’s.

Kristin Loomis suggested ME/CFS patients who’ve tested positive for HHV-6 (via quantitative PCR) probably have ciHHV-6. The question then becomes whether they also have an active infection or if your test merely reflected the fact that you have ciHHV-6.

This is the tricky part. ciHHV-6 infection can result in false positives for active HHV-6 infection but this study involved four ME/CFS patients with inherited ciHHV-6 infection. This suggests ciHHV-6 infected ME/CFS patients may be at greater risk of succumbing to an outside strain of HHV-6.

The Missing Test

We have two questions here. If you’ve tested positive for HHV-6 do you actually ciHHV-6? And if you have ciHHV-6, do you also have another HHV-6 infection?

Since tests to determine if active HHV-6 infections are not available commercially, doctors will have to make informed judgments regarding treatment

The first question is relatively easy to answer. Quantitative PCR tests offered by commercial laboratories can suggest you have ciHHV-6. Since ciHHV-6 is expected to produce high DNA copy numbers, and CFS patients with persistent low-level HHV-6 infections almost always test negative (or fall below the level of detection) for HHV-6, any quantitative PCR DNA lab tests indicating high HHV-6 loads very strongly suggests that you have ciHHV-6.

(Note: This does not apply to persons testing positive on the qualitative nested PCR tests at VIP Laboratories or Redlabs.)

Unfortunately, no commercial laboratories offer tests that can tell if you have an active HHV-6 infection.

Physicians will need to rely on their clinical assessments (ie do your symptoms suggest you have an active infection? Do immune lab tests suggest your body is fighting off an infection, etc.) to determine if antivirals are indicated.

Kristin Loomis suggested that those with a positive plasma test in the past should send blood samples to the clinical lab University of Washington to confirm CIHHV6 status, using a form that can be downloaded from the HHV-6 Foundation page on CIHHV6 testing. The University of Washington has a new third generation PCR test that is highly accurate and designed to identify ciHHV6 samples.

Testing Must Be Done on Whole Blood (Not Plasma)

Alternatively, samples can be sent to Viracor or Quest but physicians need to contact the lab director at each lab in advance to request that the testing be done on whole blood instead of plasma.

The test used in this study, a real-time PCR assay for HHV-6 U100 mRNA, can differentiate between latent and active infections but is not available in commercial labs.

A New Subset

An estimated 15,000 to 20,000 patients with this CFS-like disease in the United States alone may ultimately benefit from … this research including antiviral therapy. Dr. Peter Medveczky

Researchers propose subsetting out a category of ME/CFS patients with ciHHV-6 and HHV-6 infections.

The authors proposed to call ciHHV-6 with an outside HHV-6 infection “inherited herpesvirus six syndrome” or IHS. When asked why the ‘syndrome’ tag, Kristin Loomis replied that too much is unknown to pin the disorder down more. Several different HHV-6 scenarios, it turns out, could be causing similar symptoms. An abortive HHV-6 infection, reactivation of the integrated genome even if it is not fully replicating, or even ciHHV-6’s interference with genetic functioning of the chromosomes its found in, could all potentially cause similar symptoms.

Medveczky explains that IHS patients are:

ciHHV-6 positive

suffer from an illness similar to ME/CFS,

have HHV-6 mRNA (late mRNA) present in their blood indicating the virus is active

respond to six weeks of antiviral treatment with the disappearance of the active virus and experience symptom improvement

Since ciHHV-6 is found in all the cells of the body it’s potential to wreak mischief either genetically or through reactivation is high. It will take future studies to determine if it does, however. Medveczky found that HDAC inhibitor Trichostatin A activates CIHHV6 in the test tube. Many of the new cancer treatments, such as Vorinostat, are HDAC inhibitors.

Good Pedigree

The senior author of the study, Dr. Peter Medveczky, has been publishing herpesviruses papers since the 1980’s. HHV-6 Foundation president, Kristin Loomis, noted that Medveczky was completely skeptical when he first heard about ciHHV-6 but he’s now convinced, and he’s actively linking a subset of ME/CFS to a viral disorder. With his long stint of herpesvirus research behind him, Medveczky is the kind of researcher other researchers listen to – a vital need.

Conclusion

Doubled rates of ciHHV-6 in ME/CFS relative to the general population suggest ciHHV-6 could contribute to ME/CFS. The high viral loads in laboratory tests, present in people with benign ciHHV-6 infections, can lead to unneeded courses of antivirals. On the other hand, some evidence suggests ciHHV-6 associated immune dysfunction may open the door for further herpesvirus infections.

This early study indicates new HHV-6 infections may be commonly found (and effectively treated) in ME/CFS patients with ciHHV-6. Further study is needed but the success of long term antiviral treatment regimes (@ 6 weeks) in these patients suggests from 15-20,000 ME/CFS patients in the U.S. could ultimately benefit from appropriate courses of antivirals. Shorter-term courses are not effective.

Since persistently high levels of HHV-6 are associated with ciHHV-6 status but not chronic HHV-6 infection, further testing, while not definitive, can help determine whether ciHHV-6 is present. Physicians will need to decide on a case-by-case basis if antiviral treatment is warranted. Quantitative PCR tests done on whole blood can suggest whether ciHHV-6 is present. No commercial laboratory tests at this time can determine if an active HHV-6 infections are present.

Further Studies

All one study can do is open the door; it takes confirmatory studies to make the findings stick. If a sub-category of ME/CFS called Inherited Human Herpesvirus Six Syndrome is to take hold substantial research is needed. Small research foundations like the HHV-6 Foundation can only do so much. Thus far the work has been done on a shoestring; now it needs full funding and that means NIH funding.

Round-Table

Some of the top ME/CFS practitioners had a meeting of the minds on how best to treat ME/CFS at the Simmaron Roundable

Simmaron Research likes to get people talking. At the FDA Workshop earlier this year, they booked a room, invited patients and physicians and then held a physicians round-table with some of the field’s top doctors.

Part II of a three-part series focuses on Dr. Peterson of Sierra Internal Medicine /Simmaron Research Institute, Dr. Klimas – the director of the Center for Neuroimmune Studies at Nova Southeastern University, and Dr. Enlander, the Director of the Mt. Sinai ME/CFS Research Center talking about chronic fatigue syndrome treatment.

Dr. Peterson – Simmaron Research Institute

Dr. Peterson started off the treatment section with some hopeful news. Powerful new immune drugs such as immune modulators and cytokine blockers), he said, that have been and are being developed, can have dramatic effects in the right patients.

Immune therapies under development in other fields may be able to help ME/CFS patients in the future.

(Rituximab is an example of a new approach that paid off. The first of its class of drugs (monoclonal antibodies), Rituximab (Rituxan) opened up a new arena of drug development. Similarly, Ampligen and other Toll-like receptor affecting drugs offer new approaches to immune modulation. Drug repurposing efforts that are finding new uses for old drugs present some intriguing possibilities. An abortifacent, mifepristone, for instance, boosts natural killer cell functioning.

Breakthroughs in other fields are providing other opportunities. Studies documenting the role natural killer (NK) cells and the innate immune system play in preventing cancer have piqued drug developers interest enough the several NK cell boosting drugs are in development.

A Treatment Philosophy

Some ME/CFS patients, believe it or not, are relatively easy to treat. Patients with easily characterized viral infections have a clear treatment protocol waiting for them. If a parvovirus infection is found, for instance, it can be easily treated. Dr. Peterson has found that the ‘wait and see’ approach so often prescribed by doctors with ME/CFS in hopes that the patient will just get better is a mistake. He’s found that, in his group of patients, treating aggressively early is more effective.

Dr. Peterson proposes more aggressive approaches to ME/CFS early may forestall problems later if the disorder progresses.

(This brings to mind the story of someone I know whose doctor used a less strong antiviral (Valtrex) for a significant period of time only to switch to a stronger but potentially more toxic antiviral (Valcyte) after his patient deteriorated significantly. The patient then experienced a dramatic and lasting recovery.)

We’ll see that fighting pathogens in ME/CFS is not a cut-and-dried, one-size-fits-all process, and that physicians differ somewhat in their approach. In more complicated cases, for instance, Dr. Peterson is experimenting with combining immune and anti-viral treatments, and thus far is getting some encouraging results.

Dr. Peterson’s use of the antiviral Cidofovir (typically used to fight eye infections caused by cytomegalovirus in AIDS patients) demonstrates how differently even this small group of physicians sometimes approaches infections.

Cidofovir (Vistide)

“Cidofovir is not a panacea for this disease, but I think it demonstrates clearly how we should be subsetting and treating the treatable people,” Dr. Peterson.

Dr. Peterson uses Cidofovir regularly in patients with documented HHV6 and cytomegalovirus (CMV) infections. (Since he employs more spinal taps than the other doctors at the Roundtable, he probably also finds more HHV6/CMV infections.)

Gunnar Gottschalk, Dr. Peterson’s research assistant, gave an overview of the Vistide results seen in Dr. Peterson’s practice. Vistide is an expensive drug with potentially serious side effects that requires a rather complex infusion process. Most patients need to relocate to the Reno/Lake Tahoe area to get at least 12 infusions. Once they start the infusions they need to get three blood tests a week. Vistide is difficult to administer, and its no surprise that most ME/CFS docs are not using it.

Gunnar reported, however, that a retrospective analysis indicated that 70% of ME/CFS patients with HHV6/CMV infections achieved a positive response. He highlighted three patients: two achieved substantial gains in VO2 max and their viral titers dropped to zero, and all three returned to work after being disabled.

The retrospective analysis indicated significant drops in viral titers, increases in VO2 max (but not to normal) in full responders, and increased NK cell functioning in the group as a whole. Of the full responders Gunnar estimated two-thirds were able to maintain their health and one-third had to restart the treatment after 6-8 months.

When asked to compare Valcyte’s side effects with Vistides, Gunnar said that his experience was that people appeared to have a harder time on Valcyte than Vistide.

CMX001

Then there’s CMX001, the lipid-based analogue of Cidofovir produced by Chimerix that appears to be both more potent and better tolerated and which is beginning phase III (final) trials.

If CMX001 passes muster at the FDA it will present new possibilities for herpesvirus treatment in ME/CFS

Simmaron believes it has patients that will fit Chimerix’s criteria and is trying to get them into the trials. (Chimerix, by the way, generated $118 million dollars in gross proceeds when it went public a couple of months ago. Chimerix projects Phase III trials for CMX001 treatment of CMV infections in stem cell transplant patients will be finished in 2015. Since the drug is on fast-track status, the FDA will rule on it more quickly than usual once the data is in). Exactly what Vistide is doing (besides knocking down the virus) is unclear.

On the immune end, it’s possible Vistide is relieving pathogen-associated NK cell dysfunction (although Dr. Peterson thinks more than that is going on) but it’s unclear why the VO2 max readings in his patients go up. Gunnar did allude to the fact that some deconditioning probably was present in these very disabled patients, but Dr. Peterson thinks cytokine induced mitochondrial dysfunction may be occurring.

HHV6 and Chromosomal Integration

The tricky problem of HHV6 chromosomal integration should be noted. People who have HHV6 integrated into their chromosomes will always, whether the virus is active or not, test positive for HHV6 via PCR. Retrospective studies are never proof of a drug’s effectiveness; you need a placebo-controlled, double-blinded study for that. But retrospective studies do provide the pilot data that could support a trial. (I was told that Dr. Peterson’s Paris presentation generated a lot of interest.) This retrospective study is an instance of a doctor combing through and analyzing their past data, and hopefully we’ll see more of it in the future.

Graded Exercise and Cognitive Behavioral Therapy

“I wish graded exercise and cognitive behavioral therapy worked,”said Dr. Peterson. After mentioning the CDC toolkit (which emphasizes CBT and GET and does not suggest ANY laboratory testing be done) Dr. Peterson said he wished CBT/GET worked, and then said it might be helpful for patients who’ve gotten well enough, but that even if it was, it’s simply not available. For all the talk on CBT and GET, Dr. Peterson knew of no trained practitioners in the US, except for one associated with Dr. Klimas’ clinic.

Dr. Nancy Klimas – Director of the Center for Neuroimmune Studies at Nova Southeastern University

“I’m a splitter not a lumper. I try very hard to find …intervention points,” Dr. Klimas

An Autonomic Nervous System Focus

Earlier this year Dr. Klimas reported that gene expression tests done during and after exercise suggested that the autonomic nervous system ‘tanks’ first in ME/CFS during exercises, and then drags down the immune system with it. Her research suggests autonomic nervous system problems trigger an ‘inflammatory cascade’ which then causes much of the post-exertional malaise that occurs in this disorder.

Dr. Klimas exercise studies suggest the problems in the autonomic nervous system trigger problems in the immune system

It was no surprise, then, to hear her say that she spends a great deal of time early on with her patients trying to get that ‘volatile’ autonomic nervous system under control. (This is an example of translational medicine; i.e., translating research results (gene expression findings) into practical applications in the clinic.) This ANS-immune cascade problem, by the way, appears to be independent of pathogen or antibody results; it’s a core issue present in many patients.

Pathogens and Immune Modulation

With regard to pathogens, Dr. Klimas said most of her patients with high antiviral loads/antibodies will be on antivirals, but generally more gentle ones such as Famvir (famciclovir). She noted, though, that a danger lurks when less-strong drugs inadequately control the virus: it can then ‘break free’ and develop resistance not just to that drug but to others in its class. A virus that develops resistance to Famvir, for instance, will probably also be resistant to Valcyte. Dr. Klimas then made a plug for controlled clinical trials of Vistide in ME/CFS.

“We don’t really know how to distinguish which group is autoimmune and which group has chronic viral activation”

One has the feeling that the only thing keeping Dr. Klimas, an immunologist, from tinkering more with the immune system in her patients was lack of sufficient data. Referring to the weird immune ying/yang often seen in ME/CFS (some parts of the immune system being over-activated and some parts under-activated), she said she’d love to be able to knock down the immune activation present and build up immune cell functioning, but that building up cell functioning in a patient whose immune system is already overcharged could trigger an autoimmune response. Since no autoantibodies have been associated with ME/CFS, it’s difficult to tell if an autoimmune response is already present.

Some indirect tests can help; high CD4/CD8 ratios, for instance, are suggestive of autoimmunity, and high CD8 levels suggest a pathogen is present. If her flow cytometry tests show high CD4/CD8 ratios, she’s ‘very nervous’ about doing anything to bump up the immune system.

Immunovir (Isoprinosine)

Dr.; Klimas has had good success with Isoprinosine in ME/CFS

Dr. Klimashas seen an 85% response rate to Immunovir biologically, and it can generally double up NK cell functioning. She obtains pharmaceutical grade Immunovir from Canada Newport Pharmaceuticals and a similar and cheaper over-the-counter preparation called Inosine is available in the US. Anecdotally she doesn’t think she’s getting as good a response from Inosine. Equilibriant – includes mushroom extracts that enhanced NK function in Chinese studies. Got lots of stuff in there.

Monoclonal Antibodies

A group of patients with extraordinary immune readings; i.e., TNF-a levels hundreds of times above normal, are prime targets for monoclonal antibody drugs (such as Etanercept) that target specific immune factors. In these patients, Dr. Klimas usually brings in a rheumatologist to get the drug.

Expect more news on this in the future, as a great number of monoclonal antibodies coming out of cancer research should be hitting the market, some of which may be able to assist NK functioning. Dr. Klimas said there’s “Some pretty cool stuff in the pipeline”.

“I want to make a plug for Low Dose Naltrexone” Dr. Klimas

Low Dose Naltrexone

Low Dose Naltrexone (LDN), not Lyrica or Cymbalta, is Dr. Klimas’ first line treatment for fibromyalgia-type pain. A recent study found that it reduced FM pain by roughly 60% without the toxicity of Lyrica and Cymbalta. She called the science behind LDN (which is not produced in a low-dose form by drug companies but is readily available at compounding pharmacies) ‘riveting’. That’s pretty strong endorsement of an ‘underground drug’ that is getting more and more attention despite its Achilles heel of not being marketed in low-dose form by Big Pharma.

Dr. Enlander – Mt Sinai ME/CFS Research Center

GcMAF

Dr. Peterson asked about GcMAF. Dr. Klimas said she hasn’t used it, but Dr. Enlander’s been using it for two years–first by injection and now mostly in his own yogurt mixture. Dr. Cheney probably may have started the GcMAF saga in ME/CFS first with a trip to Italy several years. A yogurt mix was available, but when one of Dr. Enlander’s patients tried to make it the cost was $3,000. In the end, Dr. Enlander’s bacteriologists at Mt. Sinai produced the mixture (MAF878) (and at a cost of $120!). Dr. Enlander does believe the injections are probably more effective, but he’s gotten good results for both.

Next Up: the Future! Dr. Peterson started off with hope, and in the next section we take a look at the future for ME/CFS physicians, what their three organizations are pursuing, and what they’re looking forward to in the future.

Simmaron likes to get people talking. At just about every conference I’ve been to recently, the Simmaron Foundation has rented a room, brought in some food and got patients, doctors and researchers talking. This time at the FDA Stakeholder’s Meeting they pitched Dr. Peterson, Dr. Klimas, Dr. Lapp and Dr. Enlander questions around a physician roundtable and took questions from the patients present. We learned a lot in the off-the-cuff wide-ranging discussion that followed. In this blog we’re going to look at how these doctors diagnose their patients and next up we’ll look at treatment.

Redefining ME/CFS

“We are on the verge of better diagnostics.” Dr. Peterson

Diagnostics always come first. Before you can treat you must be able to diagnose. Unfortunately the diagnostics in chronic fatigue syndrome have been shrouded, vague, symptom-based definitions. From the myalgic encephalomyelitis to the Holmes to the Fukuda to the Canadian Consensus Criteria, the chronic fatigue syndrome field has been grasping for definitions for as long as it’s been around.

Problems on the macro level (the definition), of course, lead to problems at the micro level ( the doctor’s office) where ME/CFS doctors are deluged with all different kinds of ‘chronic fatigue syndrome’ patients. That uncertainty – not knowing just who might step in the door –surely makes for an interesting job. The qualifications for a good chronic fatigue syndrome physician may look something like this…. good listener, not daunted by complexity, loves to problem-solve, has a wide range of knowledge and is flexible and willing to try new things…

As Bernard Munos pointed out at the FDA Workshop, in a disorder like this which has few clinical trials, the physicians, more than anyone else are the innovators. Not able to rely on clinical trials, their offices are an ongoing clinical trial.

How Dr. Peterson, Dr. Klimas and Dr. Enlander made sense of their ME/CFS patients was what the first part of the Simmaron Foundation’s Physician Roundtable was all about. Listening to how the different doctors approached ME/CFS was fascinating.

“I am very concerned about random drug trials that take the first 100 patients who sign up. It would be a disaster.” Dr. Peterson

Given the many different types of patients Dr. Peterson sees, the idea of drug trials that don’t subset first is simply appalling. The idea that this complex mix of patients are ever going to respond similarly to a drug is nonsense.

For Dr. Peterson, who sees the complexity of the illness daily, diagnosis, whether in a research study, clinical trial or a doctor’s office, always comes first. Since the same symptoms can be produced by many different factors, symptom definitions, while helpful, will always have flaws. What’s needed is to ‘scientifically redefine ME/CFS’; that’s the Simmaron Foundation’s stated goal and each of these physician/researchers is working towards that.

Now onto diagnosing ME/CFS.

Immune System

“Like Dan and Nancy, we look at the patient as an immune system problem in order to develop idea of diagnosis.” Dr. Derek Enlander

Dr. Peterson started off by stating that after screening for the ‘obvious stuff’ he goes after immune markers, primarily focusing on the NK, T and B cells.

Over time he found consistent patterns began to emerge with natural killer (NK) cells playing a major role. (These cells, which play a major role in the early, innate immune response, appear to be ground zero for the immune problems in ME/CFS. Unfortunately, they’re not particularly well known in the medical community. Dr. Peterson’s poll of his colleagues in his area a couple of years ago found that few knew anything about them.)

It doesn’t help that natural killer cells are tricky to work with and need to be assessed within four-six hours of sample collection. In an attempt to make them more user friendly, Dr. Peterson is experimenting with freezing live cells in liquid nitrogen.

“We are the Gold Standard” Dr. Klimas

Being an immunologist it wasn’t surprising to see Dr. Klimas’s strong focus on the immune system. With one of the top immune labs in the country, Dr. Klimas is at the center of a lot of immune work.

Immune factors are one lab measure you’ve got to get right; tweak the powerful immune system the wrong way and you can cause a lot of trouble. If you’re using immune altering drugs, and both Dr. Peterson and Dr. Klimas do, the ability to trust your lab is critical. Dr. Klimas said her immune lab is the ‘gold standard’ and Dr. Peterson gets all his cytokine arrays done at Dr. Klimas’s lab.

Dr. Klimas will dig into IGG subclasses if she sees bacterial infections. Dr. Enlander focused on much the same factors; CD4 and 8 ratios, NK cells and function, (IL2, IL4, IL10) and uses bacterial cultures to rule out other disease entities, like Lyme, etc.

Pathogens

Pathogens were discussed briefly. All three physicians were testing for them (eg; EBV, HHV6, CMV, Parvovirus, Coxsackie and bacteria) but there were some differences. Dr Enlander did not see a relationship between viral load and disease severity, something that Dr. Peterson, as we’ll see later has found, at least with one group of patients. Dr. Klimas has not found HHV6 to be a good marker either as patients don’t test positive consistently; in fact, she called ME/CFS a ‘good day, bad day viral disease’ as patients may test negative on a good day and positive on a bad one. That’s helpful for her as a physician but is not good enough for the FDA to test treatments against. The FDA needs a test that’s consistently positive.

What does Dr. Klimas find that tracks with severity? Natural killer cell functioning and IL-5 levels might be two markers the FDA could use to assess treatment effectiveness.

We don’t hear alot about IL-5 cells but they boost two immune factors of interest in ME/CFS; mast cells and B-cells. Overactive B-cells cause autoimmune disorders and, of course, also harbor EBV as well.

Autonomic Nervous System

With Dr. Peterson stating the amount of autonomic nervous system dysfunction in ME/CFS was ‘huge’ the stage was set for the autonomic discussion. All three doctors do blood pressure and pulse testing with Dr. Peterson and Dr. Enlander doing 24-hour BP and heart testing, and Dr. Enlander and Dr. Klimas use tilt table testing. Dr. Klimas noted that an autonomic nervous system dysfunction appears to trigger immune dysfunction. She asserted that the sympathetic nervous system a major, major symptom generator in this disorder and she rattled off problems with standing, respiration, poor digestion, etc. that could all be caused by SNS overactivation.

It’s not clear how many of the physicians were measuring blood volume; it may be that they all simply assume blood volume is low, but Dr. Klimas noted the astounding fact that most patients are about a liter of blood low, or about 20% down from normal. With that little blood running through your blood vessels those blood vessels are going to have to squeeze hard to get it out to the tissues and brain, and right there you have a good reason for the sympathetic nervous system activation Dr. Klimas talked about earlier.

Dr. Klimas gives blood volume a boost with electrolytes and then puts the patients back on the tilt table to see if they’ve improved.

Dr. Enlander is using Dr. Cheney’s cardiac protocols to measure cardiac output, stroke volume, etc. He does it, interestingly enough in a variety of positions (lying down, standing) giving him a great deal of data on cardiovascular functioning.

With the ANS playing a huge role in exercise, onto to exercise testing we go.

Aerobic Testing

“You do better diagnostics when you do exercise challenges.” Dr.Nancy Klimas.

You probably couldn’t get three ME/CFS physicians more knowledgeable or committed to exercise testing in one room than you had at the Roundtable.

The first ME/CFS physician to embrace VO2 max testing, Dr. Peterson made a strong plug for Staci Steven’s test-retest, two day exercise protocol (the Stevens Protocol. This exercise test grew out of the work she did in Dr. Peterson’s office).

Dr. Peterson uses the most rigorous test of all; the aerobic exercise test to determine how well his interventions are working. At the FDA Ampligen hearing, Dr. Bateman, noted that the VO2 max test, which measures the amount of energy a person can produce, is the hardest to budge of all ME/CFS tests . Since Dr. Peterson finds that low VO2 max scores are often correlated with poor cognition, abnormalities on MRI’s and spinal fluid as well as autonomic problems, bumping up those VO2 max scores even moderately can mean a significant improvement in functionality and well-being.

All three practitioners use exercise testing in for research, disability and/or to assess the effectiveness of their interventions

( I asked Staci Stevens if she knew of any ME/CFS patients who had returned to full VO2 max functioning and she said yes, some patients on antivirals and Ampligen –coming out of, no doubt given her longstanding connection with him, Dr. Peterson’s office.)

Dr. Klimas has been digging deep into exercise in her research, lately, which, in turn is informing her diagnostic work. (That’s ‘translational medicine’). Earlier this year she reported gene expression studies indicated that the autonomic nervous system tanks first during exercise and then drags the immune system down with it.

This major finding, if validated, suggests breakdowns in the ANS, which is ever so tightly intertwined with the immune system, could be at the core of the disorder.

“Now let me tell you what we are really doing at Mt Sinai…” Dr. Enlander

And then there was Dr. Enlander who’s committing a big chunk of money to a sophisticated exercise testing study at the Mt Sinai Research Center. He’s got a geneticist, an immunologist and a pulmonologist all working together.

After exercise Enlander’s team will be looking at RNA (genes), blood (immune factors, a stool sample, RNA, DNA genome, enteroviruses), brain MRI and SPECT scan. Amongst other things Enlander will be looking to confirm or deny Dr. Chia’s findings of enteroviruse of seven, yes, seven years ago. That’s seven years without a confirmatory study of a virus that was first linked to ME/CFS decades ago…

Spinal Taps and Brain Imaging

Dr. Peterson does spinal taps to figure out what’s going on with his most cognitively challenged and neurologically impaired patients. (After decades of gathering spinal fluid, Dr. Peterson easily has the greatest store of ME/CFS spinal fluid on the planet. Dr. Mady Hornig has referred to Dr.Peterson’s spinal fluid as a precious resource).

Dr. Peterson examines the spinal fluid of his more neurologically and cognitively challenged patients

Spinal taps are where Dr. Peterson, Dr. Klimas and Dr. Enlander part ways to some extent. Both Klimas and Enlander do them at times, but Dr. Peterson does them routinely in patients with neurological and brain issues (and he does them himself). Dr. Klimas said she was astounded that Dr. Peterson found 17% of his patients’ spinal fluid tested positive for a virus.

Both Drs. Klimas and Enlander may be doing them more in the future. Dr. Klimas is waiting on finding the right neurologist, and Dr. Enlander said he was closely following Peterson’s ideas. If the CFI and PHANU studies using Dr. Peterson’s spinal fluid are positive, we may see more and more doctors turning to spinal fluid to assist with their diagnoses.

Future -Dr. Peterson looked forward to future medical advances that will help him fine-tune his diagnostic protocols. Genetic technologies are indicating, for instance, that a genetic predisposition to the NK dysfunction may be present in ME/CFS. On the other hand he also finds ‘acquired’ (ie non-genetic) NK cell dysfunction as well. He believes insights gathered from miRNA’s in the spinal fluid of ME/CFS patients, for instance, and the more rigorous pathogen detection techniques will continue to open up this field and inform his diagnostics.

Similarly, Dr. Klimas’ exercise studies are causing her to focus more on improving autonomic dysfunction, and Dr. Enlander will use his big exercise study to inform his understand of his patients. Each of these three physician/researchers is eager to translate their research findings into their diagnostic protocols.

Undefining ME/CFS?

“There is an entire school of thought in the medical profession that if anyone with chronic fatigue has anything objectively wrong with them – they don’t have chronic fatigue syndrome.”Dr. Dan Peterson

After all the talk about how to diagnose ME/CFS, Dr. Peterson brought up a trend towards ‘undefining’ that he found troubling. Undefining ME/CFS consists of putting ME/CFS patients in a different box as soon as something concrete is found. Stating that this attitude is more forceful than he ever thought, Dr. Peterson explained that a person with ME/CFS with HHV6A in their spinal fluid will be labeled as having HHV6A encephalitis and be determined to never have had ME/CFS.

Dr. Klimas acknowledged that while getting a diagnosis that can be treated is great, as a field winnowing large numbers of patients out of the ME/CFS basket could be devastating. For one it condemns ‘ME/CFS’ to be a a mere placeholder of an illness.

Dr. Klimas noted Dr. Peterson’s finding that 17% of his cognitively dysfunctional patients were culture positive for viruses in their spinal fluid was a clear subset. (She was reminded of former CDC CFS chief Bill Reeves response “you don’t know that doesn’t belong there” and she laughed and said “Wait a minute . Would it be ok for you to have your cognitively dysfunctional child culture have positive spinal fluid test? I don’t think so”). What a dilemma it was, she said when every time we start to get clarity, part of this disorder gets shuffled off into another column.

The Hidden Epidemic

And then there’s the missing patients; the bed-ridden ones that rarely get to doctors clinics and certainly aren’t in research studies. How do you define a disease without access to all the patients? The most severely ill usually get the most attention in most disorders but the opposite is true in ME/CFS. (Check out the astonishment from a former ICU nurse working with Dr. Kogelnik at the degree of disability she sees in ME/CFS. These patients, she thought, should be in a hospital, not at home.)

“Talk about a forgotten, ignored group of people.”Dr. Peterson

Dr. Peterson noted that we don’t an accurate count of how many people are in this situation. He didn’t have answers. He noted that you needed staff to get to these people and you needed to find them in the first place. Dr. Klimas answer suggested that funds were at the heart of the problem. Ads for an online CBT study did bring in bedbound patients who were unable to make it to the clinic and funding for the ‘good-day/bad-day’study did allow them to make house-calls on the patients bad days. Both Dr. Klimas and Dr. Enlander said they do do house-calls from time to time. (One of Dr. Enlanders house-calls is now up and working…he said there is hope for the severely ill.)

Listen to audio of the Roundtable in 7 parts here, and stay tuned for a blog summarizing the Roundtable discussion about treatments.

Common Infections..Sometimes Uncommon Effects

Unlike most viruses once you’re infected with herpesviruses you’re usually infected for life.

Herpesviruses are fundamentally different from most other viruses we come into contact with. Most viruses get completely eliminated from our systems but herpesviruses have found a way to stick around – usually effectively bottled up by our immune system – for a lifetime ride in our cells. Very common in humans, we’ve all been exposed to and almost all of us carry a latent or inactive herpesvirus infection.

Usually contracted in childhood most herpesvirus infections produce nothing more troubling than a childhood cold but they have a dark side. A Epstein Barr virus infection that causes a mild cold in childhood often produces infectious mononucleosis in adolescents and increase one’s risk of later coming down with multiple sclerosis and ME/CFS. A mild herpes simplex infection during childhood can turn into an painful case of shingles when we’re older.

Herpesvirus infections may be ubiquitous and usually mild but they can cause encephalitis, blindness, horrific neurological problems and inflammation if they hit the right person at the wrong time. Not surprisingly, people with impaired immune systems such transplant patients are at high risk of herpesvirus reactivation with sometimes deadly consequences.

Key Viruses in Chronic Fatigue Syndrome (ME/CFS)

A significant percentage of people may have reactivated herpesvirus infection.

Herpesviruses may play a key role in ME/CFS as well. How many people with chronic fatigue syndrome have a reactivated form of the virus is still unclear but some doctors believe the percentage is substantial. Many people begin their experience with chronic fatigue syndrome (ME/CFS) with a herpesvirus infection in the form of infectious mononucleosis.

Dr. Lerner and Dr. Glaser believe an unusual form of Epstein-Barr virus is wreaking havoc in many patients. Their model suggests proteins and enzymes produced by a partial reactivation of the virus are sending the immune system into a tizzy and causing fatigue and other symptoms. Because the current slate of herpesvirus antivirals attack the virus in the later stages of it’s development they’re in effect missing the action in ME/CFS. These drugs work to some degree. As they slowly lower viral load, the cells harboring the viruses die off over time.

Help Needed

“there remains a clear need to develop new antivirals”

The problem is that in this model the road to recovery takes time and lots of it; often a year or more of taking expensive antivirals. Dr. Lerner’s been looking for a treatment that will hit the virus just as it’s starting to replicate and he’s not alone. Even when the full virus is present, the present slate of antivirals still sometimes arrive too late to prevent blindness, neurological problems, birth defects and inflammation. The current herpesvirus antivirals come too late to the scene to

block the production of mutant viruses that can give rise to resistant strains of virus

block the expression of early viral enzymes that effect and can produce cancer in cells

block the product of viral proteins that can trigger a damaging immune response (Lerner/Glaser’s theory of ME/CFS)

A Possible Breakthrough

A new approach to attacking hard to treat herpesvirus infections could reap dividend for other viral infections as well.

“Depletion of the JMJD2 members or inhibition of their activity with a new drug results in repression of expression of viral immediate early genes and abrogation of infection. This inhibitor also represses the reactivation of HSV from the latent state in sensory neurons”

That may be changing. Researchers working at National Chemical Genomic Center (NCGC) have a developed a ‘probe’ that stops herpesviruses from replicating by pouncing on the early enzymes they use to build a new virus. (Ironically the virus uses our genetic machinery to get our bodies to produce the enzymes to build another virus). These researchers were able to design this probe after they figured out what genes these herpesviruses activate early in their life cycle. This ‘epigenetic’ approach – stopping a virus by targeting the genes it needs to replicate – may very well herald a new era in antiviral therapy.

It’s death by small cuts. By continually stopping the virus from replicating the herpesvirus will eventually die when the cell they’re living in dies. The good news for ME/CFS patients is that this probe could also whack the very enzymes Lerner and Glaser believe are causing ME/CFS. That could mean no more long, expensive and sometimes dangerous treatment regimens.

The Implications for Chronic Fatigue Syndrome (ME/CFS)

This study focused on two herpesvirus infections (cytomegalovirus (HCMV), herpes simplex) sometimes found in ME/CFS. In Dr. Peterson’s presentation in Paris on the successful treatment of HCMV infections in ME/CFS, he reported that a small subset of ME/CFS patients have an active herpes simplex infection, as did Dr. Montoya at the FDA Drug Development Workshop.

Epstein-Barr Virus and Human Herpesvirus 6?

Continued elucidation of the mechanisms and components involved in epigenetic regulation of viral pathogens will lead to additional targets for antiviral development

Epstein-Barr Virus (EBV) and Human Herpesvirus 6 (HHV6) are the pathogens most commonly associated with ME/CFS, however. I was unable to determine if the enzyme targeted by this probe is found in these viruses. The fact that the herpesvirus family undergoes a process called chromatic assembly and modulation in which the enzyme plays a role suggests the probe might be effective in other herpesviruses.The fact that the probe worked in both alpha and beta herpesviruses (EBYis a gamma herpesvirus) suggests it may have widespread application but we’ll have to see if it applies to these viruses as well.

Dr. Martin Lerner, a specialist in treating herpesvirus infections in chronic fatigue syndrome has high hope for this approach.

My own research suggest immediate early gene products initiate CFS. I think this work has great promise in effectively inhibiting many herpesviruses. Dr. Martin Lerner

Even if it doesn’t this discovery provides a new approach to drug treatment that could be duplicated in other herpesviruses. Indeed these researchers are already looking for other epigenetic targets, one of which is found in Epstein-Barr virus.

This ‘probe’ has still long way to get to the marketplace. It’s demonstrated its effectiveness in cultured cells and now needs to be assessed in animal models and humans.

This same epigenetic approaches that are effective in cancer are effective with viruses as well.

A New Paradigm for Antiviral Drug Development

There is intensive focus on the development of inhibitors of epigenetic components for the treatment of cancers and other diseases. The study presented here demonstrates that epigenetic inhibitors can also function as antiviral therapeutic agents.

The success of a drug employing a epigenetic approach to infection was big news with the study appearing in the premier scientific journal Science and the authors urging other researchers to pour resources into developing more epigenetic tools to fight infection.

“We’re Ready”

Dr. Peterson had 2 minutes to get to the point. And he did.

After 30 years of treating approximately 9,000 patients and tired of the ‘therapeutic stagnation’ in this disease, he called on the FDA to ‘execute a therapeutic strategy’ that would pave the way for drug development. No doubt speaking not just to the FDA but to drug company reps listening, he gave them good pragmatic reasons to do so; 1,000,000 sick people in the US, a $9 billion hit to our economy yearly, a market for a diagnostic marker yielding potentially $250 million a year, a drug therapy possibly bringing in billions….

He didn’t ask the federal government to do it all on their own. The ME/CFS physician community he asserted is ready to do its part. They’re already using objective markers such as NK cell functioning, MRI’s, SPECT scans, low VO2 max tests to inform their therapies and they have formed the consortia and networks needed to take on pilot studies and multi-center Phase I, II and III clinical trials.

He was backed up by his longtime colleague, Dr. Nancy Klimas later in the meeting when she said ” much of what is needed to develop drugs for ME/CFS is ‘already in hand’; we have, she said, the ‘clinical trials groups’ who have ‘many, many years of experience with these…instruments we’ve been talking about’. “There’s really no reason to delay any further”

“There’s really no reason to delay any further” Dr. Nancy Klimas on targeted clinical trials for ME/CFS at the FDA Stakeholder’s meeting

The key problem is the large heterogeneous population that makes up the ME/CFS community. Dr. Slagle of the FDA noted that the heterogeneity of the ME/CFS patient population made it necessary for researchers to define and target specific subsets, but both Dr. Klimas and Dr. Peterson asserted they’re ready, right now, to bring targeted therapies to bear on just those subsets.

This is all about one thing; scientifically redefining ME/CFS … wherever that takes us … and as long as it leads to treatments.

Scientifically Redefining ME/CFS

Dr. Peterson’s report of Vistide’s success in a retrospective study of severely ill ME/CFS with herpesvirus infections constituted not just an attempt to provide better treatment options but to redefine this illness using biological variables; in this case a subset of patients with active cytomegalovirus infections who responded to Vistide.

The Chronic Fatigue Initiative’s Hornig/Lipkin pathogen study will, with the addition of Simmaron’s spinal fluid samples, contribute to this process if they illuminate a distinct subset of patients with active viral infections, as suggested by Madie Hornig in Florida. (Results are due within the next two months.)

Now comes convincing the pharmaceutical industry that it’s worth their while to invest in this disorder, and that’s where Dr. Peterson’s request for a ‘therapeutic strategy’ that will compel pharma to enter the market comes in. That therapeutic strategy will involve the FDA identifying endpoints for subpopulations and study designs that industry will have confidence in.

The ‘Manhattan Project’

The Northern Manhattan Study is an immense project that’s taking a deep look at health in Northern Manhattan, New York . The project consists of analyzing basic health characteristics of several thousand people over time and it’s spinning out studies at a dizzying rate. The project is not on chronic fatigue syndrome, but because it’s looking at factors that have shown up in ME/CFS it may shed some light on what’s happening there. In fact it may shed a lot of light.

The ‘Manhattan Project’ is examining health issues in a wide swath of the population. Several findings may have relevance to ME/CFS/FM

For instance, each of the studies below looked at a factor that’s been found (in at least some studies) in ME/CFS and each of the findings seemed to make sense what we know of ME/CFS.

The most applicable study to ME/CFS, however, is clearly the latest one which determined if infectious disease burden was associated with cognitive declines. In this study the researchers tested blood from a broad swath of the population in New York for antibodies to common bacteria and viruses (three of them herpes viruses) and gave the participants cognitive tests. Then they created an index of infectious burden (IB) and determined if more infections meant more problems with cognition…and found they did; the more active infections present, the worse the cognitive impairment.

This study suggested that having more infections, active or latent, are associated with reduced cognition.

No ME/CFS studies have attempted to associate pathogen load with cognitive declines but given the increased rate of infections Dr. Peterson and other immunologically oriented ME/CFS doctors have found and the documented cognitive impairment in ME/CFS, the finding made sense. Cognitive impairment is associated with brain issues but the researchers didn’t zero in on the brain; instead they focused on cardiovascular problems which interfered with blood flows to the brain.

It turns out that studies have linked common infectious agents to inflammation, coronary artery disease and stroke and a past ‘Manhattan project’ study found that high infectious burdens were associated with an increased risk of stroke and increased carotid plaque buildup.

Many viral pathogens in the herpesviridae family, characterized by latent or persistent infection, were implicated in increased stroke risk.

It appears that chronic infections often play havoc with cardiovascular functioning. Infectious organisms can impact cardiovascular functioning in various ways. They can directly invade the vascular walls. C. pneumoniae and H. pylori DNA was found in aetherosclerotic lesions in 26% and 37% of cardiac bypass patients in one study. With regards to pathogens commonly found in ME/CFS, high rates of active HHV6 infection found in Italian cardiac patients who did not have aetherosclerosis suggested the virus may play a role in heart patients who have idiopathic heart disease.

Cardiovascular Issues

At the 2008 HHV6 Symposium in Baltimore, a German researcher, Dr. Lassner reported that heart biopsies he’d done in German heart patients commonly revealed parvovirus B-19, HHV-6, enterovirus and/or Epstein-Barr Virus infections. He noted that HHV-6 infection of the blood vessel walls results in the production pro-inflammatory cytokines which can constrict the blood vessels, impair capillary production and reduce heart blood flows. HHV6’s ability to trigger blood vessel wall constriction is intriguing given studies suggesting it may play a key role in ME/CFS.

Pathogens can affect the cardiovascular system and cardiovascular problems appear to be rife in ME/CFS.

Lassner, interestingly, found antivirals (IVIG-parvovirus, interferon-enterovirus) to be effective in virus infected heart patients, but reported much the same treatment response pattern found in many ME/CFS patients; improvement while on antivirals followed by relapse when off them.

Infections can also turn on the macrophages which help create the dangerous plaques, they can confuse the immune system into attacking parts of the body and they can help an inflammatory state that is damaging, etc.

These observations, along with the results of this current study lend support to the notion that past or chronic exposure to common infections, perhaps by exacerbating inflammation, may be an important etiologic factor of atherosclerosis.

Simply the presence of active herpesvirus or other infections can contribute to an inflammatory mileu that can be detrimental. Katan reported that an inflammatory state could lead to aetherosclerosis, ‘subclinical stroke’ and dementia. Subclinical strokes (ie transient ischemic attacks from which patients recover) primarily effect executive functioning, one of the cognitive processes known to be impaired in ME/CFS. Changes in mood and the ability to organize and take on multiple tasks could be a sign of a ‘subclinical stroke‘. Other symptoms can include feelings of numbness or weakness, double vision, dizziness/vertigo, confusion, inability to speak, loss of balance or coordination.

All in all the finding of decreased cognitive functioning with increased infectious burden in the Northern Manhattan Study findings may not be surprising for many people with ME/CFS. At the most recent HHV6 Conference in Paris Dr. Peterson reported on several ME/CFS patients who’s cognitive abilities rebounded remarkably following Vistide infusions for herpesvirus infections and Dr. Lerner has reported similar results in his herpesvirus infected patients.

Conclusions

The latest Manhattan project study should be helpful in highlighting not only the cognitive declines but the cardiovascular risks that are associated with common or chronic latent or active infections. Since active infections are part and parcel of ME/CFS, this study’s important association of decreased cognitive function with increased infectious burden suggests that measuring both those factors in ME/CFS should be routine, and may offer objective measurements of treatment efficacy.